PATIENT NAME: _______________________________ Weight: ____________
DATE: ___________
MRI Screening Questionaire
The following items can interfere with our MRI imaging machine and/or it can also be hazardous to your
safety. Please read each question carefully and mark yes or no next to the question. You may provide
comments or brief explanations on the line next to your answer.
1. Are you pregnant? Y N
3.
2. Do you have Brain Aneurysm clips? Y N
Do you have a Cardiac Pacemaker or lead wires implanted? Y N
4. Do you have a Pain or Insulin pump implanted? Y N
5. Do you have a Cardiac Defibrillator or lead wires implanted? Y N
6. Do you have a Neurostimulator or lead wires implanted? Y N
7. Have you ever had metal in your eyes, or have you worked in a metal shop before?
Y N
8. Have you ever had any SHRAPNEL/METAL FRAGMENTS/BULLETS in your body? Y N
9. Do you have any mechanical devices internal or external? Y N
10. Do you have any vascular clips or clamps? Y N
11. Do you have any shunts or stents? Y N
12. Do you have dentures, dental implants, braces, partial plates or bridges? Y N
13. FEMALES: Do you have an IUD or Diaphragm? Y N 14.Do you have any body piercing? Y N
15. Do you have any tattooed eyeliner, make-up or recent body tattoos? Y N
16. Do you have any metallic implants of any kind? Y N
17. Have you ever had Heart or Brain surgery before?
Y N
If so, what type of surgery?
______________________________________________________________________________
18. Have you ever had ear or eye surgery before?
Y N
If so, what type of surgery?
______________________________________________________________________________
19. Have you had any other types of surgery? Y N If so, what type of surgery?
______________________________________________________________________________
20. Are you allergic to any type of medication? Y N ___________________________________
If you answered YES to any of these questions, please advice the Tech’s as soon as possible. If you have
any questions, please feel free to ask the Tech’s at the time of your scan.
SIGNATURE: __________________________________________
DATE:_____________________
Tel: 559.226.2888 · Fax: 559.226.2887 · 108 W. Shaw Ave · Fresno, CA 93704 · mri@mrifresno.com · www.mrifresno.com